polio eradication in nigeria: the journey so...

National Polio EOC

Polio Eradication in Nigeria: The Journey so far Dr Ado JG Muhammad ED/CEO NPHCDA

Presentation to Independent Monitoring Board 1st October,2013

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Contents

▪ Emerging results

▪ Challenges

▪ Feedback from last IMB and wrap up

-- Insecurity

-- Operational

▪ Background/Status of PEI

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As of September 30, 2013 Nigeria has:-

• 48 confirmed WPV in 9 States compared to 101 cases in 11 States for the same period in 2012

• Borno, Yobe and Kano account for 72% of cases

• 3% of LGAs infected

• Reduction of circulating genetic clusters from 8 to 2

• No WPV-3 case has been detected in 2013, last case 11 months ago

• 1 confirmed circulating vaccine derived poliovirus (cVDPV2) compared to 5 cases for the same period in 2012

• Environmental surveillance detected 3 WPV in 2013compared to 18 in 2012

Nigeria polio cases as of September 30, 2013

W1 (n=48)

W3 (n=0)

cVDPV2 (n=1)

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There has been a 50% decrease in WPV cases from 2012 to 2013; also a shift from the northwest to the security compromised northwest states: Borno/Yobe

101 cases spread over northwest and northeast

W1 (n=48)

W3 (n=0)

# Infected States: 9

LGAs infected: 27


LGAs infected: 55

W1 (n=83)

W3 (n=18)

48 cases predominantly northeast and Kano

Outbreaks in polio-free states have been linked to Borno/Yobe sanctuary

60% reduction in WPV infected VHR endemic states. Out of 10 very high risk endemic states with WPV in 2012, only 4 have confirmed WPV in 2013

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2012 2013

-National EOC members relocated to HR LGAs

-Increased accountability (reward & sanctions)

-Matching best hands with worst LGAs

-Innovations such as: -Use of MST, Polio Survivors, VCMs -Doctors Against Polio -Health Camps -Engagement of Quranic school teachers etc

There has been a steep reduction in WPV cases since June 2013

Specific Interventions

Reduction in cVDPV cases and distribution, as of Week 39, 2012 & 2013

2012 2013

A 80% reduction in number of confirmed cVDPV cases in 2013 compared to same period in 2013


cVDPV2 (n=5)


cVDPV2 (n=1)

Environmental Surveillance: Declining confirmed WPV and VDPV isolates in Nigeria as of week 36,

2012 - 2013

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cVDPV2 WPV1 WPV3

• Latest WPV1 isolated in the environment was in early May 2013 (4 months ago)

• Latest WPV3 isolated in the environment was in Nov 2012 (11 months ago) • Latest VDPV isolated in the environment was in March 2013 (6 months ago)

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8 Polio SIAs have been Implemented in 2013

bOPV

tOPV

Non -Implementing States/LGAs

Feb’13 Jan’13 Mar’13

Apr’13

May’13 Jun’13 Jul’13

Sept’13

Characteristics of WPV cases (n = 41), Nigeria, 2013

Age < 36 months 56% 12 - 23 Months 29% 60+ months 17%

Residence / Location Hard to reach and rural 46%

Urban slums 39%

Nomadic From nomadic family 0%

Proximity to nomadic settlement 39%

Travel History Child travel 15% No travel 63%

Economic Status Poor 73% Educational status Koranic school & none Mother 68% Father 54%

Note: 5 WPV cases are yet to be investigated in Borno State due to security challenges

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Contents


▪ Challenges


-- Insecurity

-- Operational


Improving trends of LQAs in the 11 high risk states

26-Sep-2013

Jul-12 Oct-12 Nov-12 Dec-12 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Sep-13LGAs surveyed 145 135 161 151 143 159 174 173 174 172 154

< 60% 16% 13% 7% 5% 5% 9% 6% 5% 5% 3% 2%

60 - 79.9 % 47% 34% 35% 26% 31% 30% 30% 27% 22% 19% 25%

80 - 90 % 25% 29% 35% 31% 29% 26% 30% 29% 33% 34% 32%

>=90% 12% 24% 23% 38% 36% 35% 33% 39% 39% 44% 41%

The VVHR and VHR LGAs exhibited an increase in performance in the September campaign

29% 36% 34%

29%37%

32%33%

25%22%

40

30

20

10

0

National

target

Sep

33%

42%

2%

Jul

35%

35%

5%

Jun

33%

24%

10%

May

28%

32%

9%

Apr

26%

24%

13%

Mar

37%

20%

14%

Feb

43%

21%

2%

70

26%

36%

3%

Dec

80

90

Jan

100

110

50

60

34%

32%

5%

LQAS results over time (VVHR and VHR LGAs)

<60%

>=90%

80-<90%

60-<80%

2013 2012

11

LQAS legend

43%

15% 19%Focused interventions such

as: Management Support

Teams, Polio Survivor

Groups and Health camps in

declining LGAs have led to

improvements in IPDs

performance in these LGAs

from June to September

2013

Jun Jul Sep

45%

35% 25%

56% 22%

22%

13%

4% 0%

Upward Trajectory in the LQAs of declining LGAs

80% Target

Sub-optimal Quality of campaigns in the 2 sanctuaries Kano BORNO

YOBE Security and operational challenges are being addressed by specific interventions. Examples: - Regular meeting of Deputy Governor of Kano

state with LGA Chairmen to sustain commitment

- Engagement of LGA chairman in security compromised areas by Governor and program

- Planned meeting between PTFOPE and LGA chairmen from northeastern states in October

- Tracking commitment of LGA chairmen through the Abuja Commitment

- Use of pre-campaign and intra-campaign dashboards to measure engagement of LGA chairmen

Addressing political support in Kano HCH Kano chairing state review meeting at EOC Dep Gov Kano meeting with LGAs IMOs

Kano IMOs meeting on Polio Engagement with traditional leaders

Increasing population immunity among underserved children in Northeast sanctuary

Data as of August 13, 2103

Data from NPAFP cases

Routine Immunization progress

• Summary:

– The national coverage for DPT 3 containing antigen is 82%

– Nationally, cumulative coverage rates for BCG, MV, YF and OPV3 are

above 80% except for TT2+ National coverage 54%

– 13 States conducted >80% planned Fixed Sessions (FS) Jan-Aug 2013.

Borno is the only State that conducted <50% of Planned Fixed Sessions

– Only 3 (8%) States conducted >80% planned Out-reached Sessions

between Jan-Aug 2013.

– Nationally, 68% (1,793,099 children) reduction in no. of un-immunized

children was achieved Jan-Aug 2013 compared to same period in 2012

– 28 (76%) States achieved >50% reduction in the number of un-immunized

children between Jan-Aug 2013 compared to same period in 2012

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To sustain progress, the following is the polio SIA calendar for next six months

Dates of Polio SIA

Sub-national; Integrated with measles campaign in North Nigeria October 2013

We expanded geographic scope while maintaining/improving quality of SIA because:

1. Spread of disease to polio-free states

2. Murder of vaccinators interrupted SIA calendar – additional campaigns to catch up

Description

Imp

rovi

ng

acc

ess

in s

ecu

rity

co

mp

rise

d a

reas

*Tentative pending EOC finalization of 2014 SIA calendar

November 2013

December 2013

January 2014*

March 2014*

February 2014*

National; integrated with measles campaign in Southern Nigeria

11 High Risk States of Northern Nigeria

Special round targeted at the underserved

National Round

National Round

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Contents


▪ Challenges


-- Insecurity

-- Operational


|

Insecurity

Description Specific impact

The activities of insurgents in Borno, Yobe and Kano state have reduced access to children

▪ Threat to life and property in Borno and Yobe from Boko Haram organization

▪ State of emergency and

Interruption of communication services

▪Restrictions in movement of

personnel and supplies due to curfews ▪UNDSS MOSS restriction of UN

staff movements

▪ Inaccessibility to children; delayed outbreak response e.g. in Danbatta, MMC LGAs; limited SIA activity ▪Delayed reporting of AFP cases

by informants, delayed submission of SIA related data

▪ Staff unable to supervise and

monitor quality of RI and SIAs ▪ Transport of stool specimens to

Maiduguri laboratory impaired ▪Decreased impact of surge

capacity introduced to improve quality of program

LGAs in Borno state have been categorized by risk into Low, medium, high and very high risk with variable access to children

Category LGAs Accessibility to PEI Activities

Customized Strategies

Number of IPDs missed

Remarks

Low risk Askira, Chibok ,Hawul,Biu, Bayo, Shani& Kwaya kusar

Fully accessible All None On-going activities

Medium Risk

MMC, Jere, Guzamala, Magumeri, Abadam, Gubio, Mobbar & Nganzai

> 80% accessible PHT, Hit and Run

1-2 On-going activities

High risk Kaga ,Munguno, Marte, Ngala, Mafa, Kala Balge ,Damboa, Bama, Gwoza,

60-70% accessible

PHT, Hit and Run, Free Child health

3-4 Implementing piecemeal

VHR Kukawa, Dikwa Highly volatile Hit and Run, free Child health

=>5 Engaging with LGAs team to Resume IPDs

Geographical distribution of LGAs implementing IPDs, Borno, 2013

Feb May

Jun

Apr

Jul

n=22 n=17 n=13

n=12 n=19 n=21

Increase in number of LGAs implementing IPDs few months after State of Emergency

State of

emergency

declaratio

n

Sep

OPERATIONAL ACCESSIBILITY FOR SIAs IN BORNO (7th – 10th SEP 2013)

WPV Type 1

0 108,987 Inaccessible Children

Inaccessible children by LGA, Sep 2013 SIA

Estimated inaccessible children (<5yrs) SEP SIA 588,103 Estimated Target (<5yrs) SEP SIA 1,639,962

Inaccessible

Partially accessible

Fully accessible

Borno LQAS results and WPV cases over time

Maiduguri and Jere LGAs in Borno have consistently poor LQAS results in addition to a high incidence of WPV cases

Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13

Bayo

Biu

Chibok

Dikwa

Guzamala

Hawul

Kwaya Kusar

Marte

Mobbar

Maiduguri 1 2 1 2 1

Kaga 1

Damboa 2

Jere 1 2 1 1

Shani 1

# WPV cases LQAS result

Poorly performing LGAs

SOURCE: Integrated September dashboard

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99.8% inaccessible

due to non-

participation of

Kano and Borno

States

Non-participation of LGAs in Borno

State due to insecurity despite

state of emergency

Since 2012 there was a progressive increase in the number of Inaccessible children; however in recent months, we have secured better access

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Interventions currently being implemented:

A detailed operational plan for Borno and Yobe has been developed with specific interventions for security compromised areas

▪ Firewalling Borno/Yobe borders with health teams and health camps at borders, checkpoints, nomadic camps and motor parks in all LGAs surrounding Borno and Yobe

▪ Use of Permanent Health Teams going from house-to-house to provide health services

▪ Hit and run strategy during periods of calm to reach children with successive doses over 1-2 day bursts, with intensive supervision and monitoring to ensure a campaign of the highest possible quality

▪ Intensified RI and MNCH services bundling vaccination with free MNCH services, essential drugs, and RI in health care facilities, with provision of pluses to encourage visits and increase opportunities to vaccinate children

Interventions being supported by social mobilization efforts to raise awareness, create demand and build confidence between communities and health services

Month No of

settlements

covered

No of

Households

visited

OPV zero

dose

vaccinated

Non-zero

OPV doses

given

Proportion

of Zero

dose (%)

June 136 5559 724 17632 4

July 141 6985 495 19937 2

Total 319 14750 1319 44131

Month No of

settlements

covered

No of

Households

visited

OPV zero

dose

vaccinated

Non-zero

OPV doses

given

Proportion

of Zero

dose (%)

June 101 6494 2622 16338 14

July 85 6316 509 19708 3

Total 202 13885 3187 39990

Jere LGA

Maiduguri LGA

Increase in the number of children reached and decline in proportion of zero dose

PHT in Jere and Maiduguri LGAs, Borno State (June – July) have increasingly reached children and are being scaled up

Fire-Walling: Intensified immunization is ongoing in border communities around Borno and Yobe states to restrict spread of WPV from conflict States

1st Phase: LGAs in States bordering the conflict States

2nd Phase: Include border LGAs in the conflict areas

NIGERIA LGAs (24):

– Major traffic points = 12

– Informal & nomadic crossing points = 56

– Transit motor parks = 11

– Markets = 30

• CAMEROUN border:

– 15 districts bordering Borno State

– 134 health areas on alert to vaccinate populations from conflict in Borno State

Conflict LGAs in Borno

Niger Republic (6,000 refugees)

Total number of children vaccinated from June-September 2013: Gombe border: 12,956 Jigawa border: 6,315 Bauchi border: 1, 880 Adamawa border: Pending

Hit & Run (Modified SIAD) experience in previously security inaccessible LGAs, Borno State, June and August 2013

• WPV1 with onset on 4 April 2013

• No response mounted 2 months due to insecurity

• Rapid security assessment was done

• Conducted a one-day OPV-SIA in the ward using 4X the number of teams in June 2013

• 2713 (94%) children were vaccinated with bOPV out of a total target of 2897

• Repeat activity conducted in August

• WPV 1 with onset in April 2013

• No response in 4 months due to insecurity

• Rapid security assessment was done

• Conducted an integrated one-day bOPV - Measles SIA in the ward using 4X the number of teams in August 2013

• 5771 (79.5%) children were vaccinated with bOPV; while 921 were vaccinated with Measles vaccine

Kaga LGA, June 2013 Damboa LGA, Aug 2013

29

Contents


▪ Challenges


-- Insecurity

-- Operational


The national EOC has prioritized LGAs and taken specific actions to improve performance

Action taken

Low Political commitment

Low Accountability

Financing

Poor team performance

Non-compliance and anti-OPV campaigns

▪ Improved vaccinator training with emphasis on IPC skills ▪ Improved training of Ward Focal Persons; proper team selection

and GIS tracking of vaccinators ▪ Increased supervision by Management Support Teams (MST)

▪ Engagement of Monitoring and Accountability Officers to track

planned activities and report on corrupt practices ▪ Immediate sanctioning of errant vaccination team members and

recognition of outstanding performance

▪ Showing pro-OPV videos in football viewing centers, Bluetooth distribution ▪ FAQ focused on evolving questions to communities ▪Addressing felt needs with pluses: antimalarials, ORS, health camps ▪Use of Polio survivors, VCMs, Doctors against Polio, religious leaders

▪ Institutionalization of basket funding for immunization activities ▪ The Tripartite agreement with Dangote, BMGF and Kano Government is

strengthening RI in Kano state ▪ Finance committees of LGA task forces oversee transparent

disbursement of funds for immunization activities

▪ Competition among Chairmen for best performing LGA

Type of challenge

▪ Engagement of LGA Chairmen and Governors by Mr. President ▪Use of dashboards as advocacy tools to LGA Chairmen and Govs

▪ Intensified engagement of Governors by ED/NPHCDA and PTFoPE

Intensified supervision

Focusing on low performing LGAs for MST

S/n State LGA LGA

classification

Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Priority LGAs

Criteria MST

18.00 19.00 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00

1 Bauchi Bauchi Declining 1 5 6 11 13 11 9 7 5 Yes NC Yes

2 Kaduna Birnin Gwari Declining 14 23 17 13 3 4 22 12 7 1 Yes NC/SEC Yes

3 Kaduna Giwa Declining 34 4 4 11 6 15 9 7 7 Yes NC Yes

4 Kaduna Igabi Declining 37 18 6 16 11 17 16 24 Yes NC Yes

5 Kaduna Kaduna North Declining 18 26 20 22 3 17 18 8 Yes NC Yes

6 Kaduna Kaduna South Stagnant 11 9 4 1 10 9 3 6 7 Yes NC Yes

7 Kaduna Kudan Stagnant 12 11 21 3 8 14 14 11 4 Yes Yes

8 Kaduna Sabon Gari Declining 9 1 13 11 28 12 4 16 6 Yes NC Yes

9 Kaduna Soba Declining 20 6 17 9 23 12 19 3 1 Yes Yes

10 Kaduna Zaria Declining 3 13 4 14 32 33 23 31 19 4 Yes NC Yes

11 Kano Fagge Declining WPV 1 15 Yes NC Yes

12 Kano Dambatta Declining 11 3 2 12 10 12 Yes Yes

13 Kano Gezawa Declining 15 2 25 4 11 Yes Yes

14 Kano Kumbotso Declining 5 4 5 14 11 15 16 17 Yes Yes

15 Kano Nasarawa Declining 31 6 26 39 11 26 YES NC/SEC Yes

16 Kano Takai Improving 6 6 18 4 Yes Yes

17 KANO Tofa Declining 10 15 22 3 Yes Yes

18 Kano Tarauni Declining 5 2 Yes NC/SEC Yes

19 Kano Ungogo Stagnant 10 12 13 4 13 18 37 16 Yes NC/SEC Yes

20 Katsina Funtua Declining 18 24 0 11 1 5 4 23 18 7 Yes NC Yes

21 Katsina Kankara Declining 3 5 Yes NC Yes

22 Katsina Kankia Stagnant 11 11 9 14 9 2 1 6 Yes Yes

23 Katsina Katsina Declining 19 20 30 22 12 17 29 Yes NC Yes

24 Kebbi Birnin Kebbi Declining 5 16 8 16 4 14 8 2 13 Yes NC Yes

25 Kebbi Jega Declining 15 15 18 27 14 19 27 17 19 8 Yes NC Yes

26 Sokoto Kware Declining 17 12 8 19 2 20 10 9 18 Yes NC Yes

27 Sokoto Sokoto North Stagnant 10 22 13 10 12 17 1 1 Yes NC Yes

28 Sokoto Sokoto South Declining 17 14 15 15 32 33 13 20 16 Yes NC Yes

29 Sokoto Tambuwal Declining 12 27 1 3 Yes NC Yes

30 FCT Bwari 11 6 7 Yes Yes

Piloting Health Camp Strategy in a persistent non-compliant and poor performing ward in Kaduna South LGA, July 2013 IPDs

Comparison of Children vaccinated June (fixed post) Vs July 13 IPDs (Health camp), Ung. Muazu Ward

Day of IPDs June 13 IPDs (Fixed Post)

July 13 IPDs (Health Camp)

Day 1 24 240

Day 3 24 273

Day 4 23 100

Total 71 613

A 760% increase in children vaccinated with OPV in the health camp in Ung. Muazu ward compared to a traditional fixed post

Expanding Health Camps implementation during Sept 2013 IPDs

• In VVHR and VHR LGAs:

– Focused on 70 VVHR and VHR LGAs (EOC-WHO-CDC-Global Goods ranking June 2013)

– Selected wards within these LGAs that have persistent non-compliance due to unmet needs

– NPHCDA and WHO at central level supported provision of simple health interventions in the prioritized wards

• In Other LGAs:

– State and LGAs procured health interventions for non HR wards

– State and LGAs provided health

personnel to man the health camps

• Number of centrally supported health camps in 70 VVHR and VHR LGAs:

Kano = 181

Kaduna = 107

Katsina = 37

Bauchi = 30

Niger = 10

Large turn-out at a health camp, in non-compliant Funtua LGA, Katsina, Sept 2013 IPDs

34

Contents


▪ Challenges


-- Insecurity

-- Operational


35

What we did to address community demand

Description

Aggressive pro-OPV campaigns

Intensified community engagement

▪500,000 copies of pro-OPV CD distributed at household level & at viewing centres, Islamiya schools ▪Dialoguing at Islamiya schools and health facilities ▪Bluetooth campaign with pro-OPV/immunization messages ▪Engagement of popular Hausa celebrities to promote immunization

Interventions

▪ 214 religious leader focal points engaging local mallams ▪>1000 polio survivors actively supported the September IPDs ▪Doctors Against Polio (DAP) deployed – for polio & offering

broader health consultations ▪Addressing other felt needs – using health camps, linking to

nutrition & RI

Intensified Household engagement

▪ Expansion of volunteer mobilizer network (soon to be >8000 in high risk settlements) ▪ Immunizing zero-dose children on site ▪Linking to facilities for nutrition and Routine immunization ▪Using naming ceremonies as an opportunity to discuss

immunization & immunize

36

Intensive program communication has led to a 70% reduction in non-compliance form Jan-Sept 2013

30% of cases missed due to non-compliance compared to 50% in 2012

▪ All clustered in the 4 states with

the most cases: Bauchi, Borno, Yobe, and Kano

Poor community education is the

primary reason for non-compliance

Religious non-compliance going

down in Bauchi & Yobe Kaduna, Kano & Katsina have

demonstrated improved performance in the past 7 months:

20,447 new births recorded in VCM network 16,584 given 0 dose by/with support of VCM 17,679 linked to facility for RI 14,297 naming ceremonies attended by VCM

Summary and Way Forward

• Nigeria made good progress to interrupting polio transmission in the 4th quarter of 2012 and beginning of 2013

• However, the steady progress was mostly affected by insecurity leading to low morale, affecting team performance and in-accessibility of children

• Innovations such as staggering to reach children in poor performing LGAs and the insecurity / conflict areas are being rapidly scaled up

• Integration of OPV with other RI antigens and simple health interventions provide an opportunity to reach more children

Remaining challenges to the programme

• Insecurity and conflict remains the greatest threat to the programme resulting in inaccessibility of targeted children

• Existence of some persistently poor performing LGAs despite the efforts

• Borno, Yobe and Kano account for 72% of 2013 cases and special initiatives are underway to improve access and performance

• Migration of people from conflict states with high WPV transmission to other states within the country and across international borders pose a risk of outbreaks

• Strengthening surveillance where gaps have been identified

• Funding gap for planned activities especially new innovations

Thanks

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